Massive Transfusion Protocol Ups RBCs, Plasma

SAN FRANCISCO - From the front lines of war comes a new protocol for preserving life during massive blood transfusion to treat maternal hemorrhage.

Physicians providing trauma care during the Iraq war noticed that giving fresh frozen plasma earlier to patients requiring massive transfusion and making a few other changes in conventional transfusion protocols decreased coagulopathy and improved the well-being of patients, Dr. Mark D. Rollins said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Subsequent retrospective studies in civilians and a prospective study that was completed this year supported the military's suggestion that increasing ratios of plasma and platelets to red blood cells (RBCs) would improve survival in massive transfusions.

Responding to these new ideas, the California Maternal Quality Care Collaborative convened an Obstetric Hemorrhage Expert Task Force, which incorporated these cutting-edge recommendations into a free Obstetric Hemorrhage Toolkit (available at www.cmqcc.org/ob_hemorrhage).

"I'm not saying we have a ton of evidence," but the limited evidence available was sufficient to justify modifying protocols for managing maternal hemorrhage, said Dr. Rollins, an obstetric anesthesiologist at the university and a member of the California Maternal Hemorrhage Collaborative.

The military observations, published in 2007 (J. Trauma 2007;62:112-9), were followed by a retrospective study of 466 civilians who underwent massive transfusions at 16 U.S. trauma centers (Ann. Surg. 2008;248:447-59). That study found better survival using increased ratios of plasma and platelets to RBCs in massive transfusions.

Conventional guidelines called for a 1:3 ratio of plasma to RBCs; the military called for a 1:1 ratio, with no recommendation for the ratio of platelets to RBCs. The civilian study found 30-day survival was 60% in patients who got more than one unit of plasma or platelets per two units of RBC, compared with 40% survival with lower ratios of plasma or platelets to RBCs, so the investigators recommended a 1:1:1 ratio of plasma, platelets, and RBCs in massive transfusions.

A randomized, controlled trial of 214 civilian trauma patients, completed this year by Dr. Rollins and his associates, found significantly increased 30-day survival rates with higher ratios of plasma, platelets, or cryoprecipitate to RBCs in massive transfusions, defined as more than 10 RBC products transfused within 24 hours (Transfusion 2010;50:493-500).

Survival was 59% after transfusions with at least one unit of plasma per two of RBCs, compared with 44% with ratios of 1:3 or more. For platelets, survival rates were 63% with at least 1:1 ratios, compared with 33% with ratios of 1:2 or more. Higher ratios of cryoprecipitate to RBCs improved survival, compared with lower ratios: 66% vs. 41%, respectively.

In developed countries, hemorrhage causes 13% of maternal deaths and is the third-leading cause of maternal death, with higher rates in other countries (Lancet 2006;367:1066-74). Death rates from postpartum hemorrhage have increased from approximately 2% in 1994 to 3% in 2006 in the United States, and from 4% to 5% in Canada during that time.

"In the past couple of years, we've had two or three deaths right here in the San Francisco Bay Area in our hospitals from maternal hemorrhage," Dr. Rollins said.

He reported having no conflicts of interest related to these topics.

Managing Massive Transfusions

For best management of massive obstetric transfusion, consider these steps, Dr. Rollins said:

Get into good communication with your blood bank, and ask for supplies for massive transfusions in packs of multiple units of RBCs and fresh frozen plasma--potentially even platelets--that arrive together. "This just helps remind everyone as those packs arrive that they should be giving the fresh frozen plasma with the red cells," he said. Make sure the blood bank knows exactly which room you're in.

Have a team ready to mobilize, including a second anesthesiologist, a second surgeon, additional nurses, and runners for laboratory tests and blood products.

Move expeditiously to an operating room if you're not already in one.

If you're considering options such as interventional radiology, call those teams early to give them time to set up.

Place large-bore IVs (16- to 14-gauge). "I like to think that goes without saying, but plenty of times I've had people come in with just 20-gauge IVs put in, and you can't transfuse enough through them to make a difference," Dr. Rollins said.

Place invasive monitoring equipment.

Repeat laboratory tests frequently, but don't wait for results to proceed with transfusion. Results will be useful later to assess how the case developed. Use point-of-care testing if it's available for faster results.

Consider using fluid warmers and forced-air warmers to keep patients from becoming hypothermic and more coagulopathic.

Have rapid infusion pumps or pressure bags available to speed the transfusion.

Prepare for general anesthesia.

Have a team ready to mobilize, including a second anesthesiologist, a second surgeon, additional nurses, and runners for laboratory tests and blood products..

Citrates in blood products bind with calcium, increasing the risk of extreme hypotension and depressed heart function, so have a supply of calcium chloride on hand to prevent the low levels of ionized calcium that can occur after rapid transfusion.

Consider off-label treatment with recombinant factor VIIa only after the patient has received approximately 10 units of packed RBCs and full factor replacement. "It's not a first-line drug. There's plenty of morbidity and mortality that can occur" with factor VIIa, he noted. "Having said that, I do believe that it is very effective in certain situations."

Designate someone to tally and record the use of blood products and estimated blood loss.

Bring the "code cart" into the OR early.

Afterward, meet for 3-5 minutes with everyone who worked on the case to review what went well, what didn't, and ideas for improvement.